Preliminary study on predictors of early death risk in patients with exertional heat stroke
-
摘要: 目的 通过对劳力性热射病患者入院24 h检查结果进行统计学分析,寻找快速鉴别短期预后的指标。方法 将我院2016年1月1日至2022年12月31日收治的81例热射病患者,按28 d预后结果分为存活组(58例)和死亡组(23例)。对2组间基础资料、检验结果、衍生比值进行比较,并进行多因素Cox回归分析、Kaplan-Meier生存曲线、受试者工作特征曲线分析,从而寻找判断短期预后的相关指标。结果 2组间各项指标比较发现,29个指标差异有统计学意义(P<0.05)。多因素Cox回归分析提示,谷草转氨酶/谷丙转氨酶比值(P=0.02)和血小板分布宽度(P=0.04)是影响热射病患者预后的独立危险因素。Kaplan-Meier生存曲线发现,谷草转氨酶/谷丙转氨酶比值与患者的生存状况具有显著相关性(P < 0.001),而血小板分布宽度与患者的生存状况无相关性(P>0.05)。受试者工作特征曲线分析显示,谷草转氨酶/谷丙转氨酶比值预测劳力性热射病患者预后的曲线下面积为0.738。结论 谷草转氨酶/谷丙转氨酶比值可作为预测劳力性热射病早期死亡风险的指标,用于指导急诊科医生分层治疗。
-
关键词:
- 劳力性热射病 /
- 短期预后 /
- 谷草转氨酶/谷丙转氨酶 /
- 预测指标 /
- 分层治疗
Abstract: Objective To explore indicators for rapid identification of short-term prognosis of patients with exertive heat stroke by conducting statistical analysis on the 24-hour examination results of patients with occupational heat stroke upon admission.Methods A total of 81 patients with heat stroke who admitted to our hospital from January 1, 2016 to December 31, 2022 were divided into survival group(58 cases) and death group(23 cases) according to 28-day prognosis. The basic data, test results and derived ratio were compared between the two groups. Multivariate Cox regression analysis, Kaplan-Meier survival curve and receiver operating characteristic curve analysis were used to find out the related indicators to predict the short-term prognosis.Results The comparison of various indicators between the two groups showed that there was a statistically significant difference in 29 indicators(P < 0.05). Multivariate Cox regression analysis showed that the ratio of aspartate aminotransferase to alanine aminotransferase(P=0.02) and platelet distribution width(P=0.04) were independent risk factors affecting the prognosis of patients with heat stroke. Kaplan-Meier survival curve showed that the ratio of aspartate aminotransferase to alanine aminotransferase was correlated with the survival condition of patients(P < 0.001), while the platelet distribution width was not correlated with the survival condition of patients(P>0.05). The receiver operating characteristic curve analysis showed that the area under the curve of the ratio of aspartate aminotransferase to alanine aminotransferase for predicting the prognosis of patients with exertional heat stroke was 0.738.Conclusion The ratio of aspartate aminotransferase to alanine aminotransferase can be used as an index to predict the risk of early death in exertional heat stroke, which can be used to guide emergency physicians to stratified treatment. -
-
表 1 2组间基线资料、生命体征、血气分析结果比较
指标 存活组(58例) 死亡组(23例) t/F P 男/例(%) 39(67.24) 21(91.30) 5.66 0.02 年龄/岁 23.00(21.00,26.75) 32.00(23.00,40.00) 3.84 <0.01 平均动脉压/mmHg△ 85.67(78.83,88.83) 81.67(62.33,88.50) -1.54 0.14 体温/℃ 37.64±1.26 38.50±1.70 2.49 0.02 呼吸/(次/min) 23.09±7.22 26.04±9.25 1.53 0.13 心率/(次/min) 93.31±22.43 125.13±29.21 5.27 <0.01 氧分压/mmHg 133.02±36.29 92.57±32.92 -4.60 <0.01 二氧化碳分压/mmHg 29.68±7.76 30.35±7.52 0.35 0.72 二氧化碳含量/(mmol/L) 22.12±4.13 21.99±5.68 -0.11 0.91 pH值 7.37(7.17,7.63) 7.33(6.23,7.62) -1.98 0.06 △1 mmHg=0.133 kPa。 表 2 2组间血生化指标和衍生比值结果比较
指标 存活组(58例) 死亡组(23例) t/F P 血常规指标 白细胞计数/(×109/L) 7.82(3.00,20.90) 11.50(4.41,28.78) 2.68 0.13 NEU/(×109/L) 5.32(0.75,17.48) 8.36(2.04,23.89) 3.04 0.01 淋巴细胞计数/(×109/L) 1.79(0.43,4.12) 0.84(0.19,9.18) -0.18 0.86 红细胞计数/(×1012/L) 5.01(3.91,5.89) 4.95(3.12,5.60) -2.01 0.54 RDW/% 41.05(36.60,50.00) 41.50(37.20,53.20) 2.23 0.03 血红蛋白/(g/L) 148.50(111.00,179.00) 145.00(87.00,191.00) 4.63 0.05 红细胞压积/% 0.43(0.34,0.50) 0.41(0.29,0.55) -1.04 0.31 PLT/(×109/L) 208.44±60.17 118.04±84.18 -5.42 <0.01 PDW/% 12.89±2.55 14.72±4.57 2.30 0.02 炎症指标 IL-6/(ng/mL) 5.23(3.78,7.45) 46.30(32.61,106.25) 2.31 0.01 PCT/(ng/mL) 0.05(0.02,0.87) 3.20(0.07,100.00) 2.58 0.02 凝血指标 PT/s 11.40(9.70,19.30) 14.10(7.20,120.00) 3.21 <0.01 APTT/s 26.70(18.30,40.20) 29.50(17.00,119.40) 2.66 0.01 INR 0.99(0.85,1.83) 1.34(0.89,6.24) 4.15 <0.01 D-D/(μg/mL) 0.25(0.03,58.00) 3.24(0.41,47.74) 2.43 0.02 心功能指标 Lac/(mmol/L) 2.75±3.19 5.03±4.18 2.64 0.01 B型钠尿肽/(pg/mL) 25.45(15.18,44.41) 812.00(63.82,2 812.00) 1.96 0.06 肌酸激酶同工酶/(IU/L) 3.40(1.43,8.05) 48.20(5.10,100.40) 1.18 0.25 肌钙蛋白/(IU/L) 0.02±0.05 16.41±68.10 1.15 0.26 MB/(IU/L) 53.38(28.10,97.50) 748.00(172.10,3 514.00) 4.25 <0.01 LDH/(IU/L) 206.00(184.00,234.50) 503.00(331.00,1 331.00) 2.37 0.03 肝功能指标 总胆红素/(μmol/L) 14.05(3.78,53.80) 19.00(7.60,161.60) 2.65 0.14 DBIL/(μmol/L) 6.55(1.70,11.70) 8.40(1.50,111.60) 4.34 <0.01 ALB/(g/L) 45.40±4.70 39.21±10.37 -2.75 0.01 球蛋白/(g/L) 28.91±4.39 27.05±6.40 -1.29 0.21 AST/(IU/L) 24.50(9.00,91.00) 123.00(12.00,6 658.00) 4.09 <0.01 ALT/(IU/L) 19.00(6.00,192.00) 45.00(7.00,6 552.00) 3.62 <0.01 ALB/球蛋白 1.61±0.31 1.53±0.42 -0.84 0.46 肾功能指标 Cr/(μmol/L) 96.00(61.00,169.00) 170.00(62.00,494.00) 3.96 <0.01 BUN/(mmol/L) 5.30±1.88 8.84±5.84 4.14 <0.01 尿酸/(μmol/L) 407.19±127.81 492.39±190.31 1.98 0.06 衍生比值 血红蛋白/RDW 3.58±0.51 3.29±0.70 -1.82 0.08 RDW/ALB 0.91±0.11 1.18±0.36 5.17 <0.01 RDW/PLT 0.20(0.12,1.61) 0.46(0.12,11.05) 2.79 0.01 D-D/PLT 1.30×10-3(9.60×10-5,0.24) 0.05(1.20×10-3,2.42) 3.62 <0.01 D-D/ALB 6.00×10-3(5.80×10-4,1.19) 0.07(9.60×10-3,1.57) 3.65 <0.01 D-D/B型钠尿肽 9.30×10-3(8.30×10-4,4.52) 7.30×10-3(2.80×10-4,0.81) -0.62 0.53 D-D/肌钙蛋白 28.25(1.39,11 600.00) 12.58(4.20×10-3,285.00) -1.13 0.26 PT/INR 12.11±2.54 12.25±5.09 0.13 0.90 AST/ALT 1.26±0.63 1.86±0.94 2.81 0.01 表 3 AST/ALT、PDW预测劳力性热射病患者短期预后的ROC曲线分析
项目 AST/ALT PDW 曲线下面积 0.738 0.620 最佳截断值 1.36 15.40% 灵敏度/% 73.91 34.78 特异度/% 75.86 87.93 95%CI 0.61~0.87 0.48~0.77 -
[1] Peiris AN, Jaroudi S, Noor R. Heat Stroke[J]. JAMA, 2017, 318(24): 2503. doi: 10.1001/jama.2017.18780
[2] Bouchama A, Abuyassin B, Lehe C, et al. Classic and exertional heatstroke[J]. Nat Rev Dis Primers, 2022, 8(1): 8. doi: 10.1038/s41572-021-00334-6
[3] Leyk D, Hoitz J, Becker C, et al. Health Risks and Interventions in Exertional Heat Stress[J]. Dtsch Arztebl Int, 2019, 116(31-32): 537-544.
[4] 于超平, 李俊杰, 尹文. 热射病相关SIRS研究进展[J]. 临床急诊杂志, 2021, 22(4): 287-291. https://lcjz.whuhzzs.com/article/doi/10.13201/j.issn.1009-5918.2021.04.014?viewType=HTML
[5] 张玲琴, 谢建刚, 王倩梅, 等. 利用转录组测序生物信息学初步探讨热射病预后关键基因[J]. 中国急救医学, 2022, 42(1): 64-67. https://www.cnki.com.cn/Article/CJFDTOTAL-ZJJY202201013.htm
[6] Laitano O, Leon LR, Roberts WO, et al. Controversies in exertional heat stroke diagnosis, prevention, and treatment[J]. J Appl Physiol, 2019, 127(5): 1338-1348. doi: 10.1152/japplphysiol.00452.2019
[7] Knoll JM, Knight LR, Quiroz D, et al. Variation in Clinical Presentations and Outcomes of Heat Stroke Victims in the Mass-Casualty Setting[J]. J Emerg Med, 2019, 57(6): 866-870. doi: 10.1016/j.jemermed.2019.08.024
[8] Yang MM, Wang L, Zhang Y, et al. Establishment and effectiveness evaluation of a scoring system for exertional heat stroke by retrospective analysis[J]. Mil Med Res, 2020, 7(1): 40.
[9] Garcia CK, Renteria LI, Leite-Santos G, et al. Exertional heat stroke: pathophysiology and risk factors[J]. BMJ Med, 2022, 1(1): e000239. doi: 10.1136/bmjmed-2022-000239
[10] Hirschhorn R, DadeMatthews O, Sefton J. Exertional Heat Stroke Knowledge and Management among Emergency Medical Service Providers[J]. Int J Environ Res Public Health, 2021, 18(9): 5016. doi: 10.3390/ijerph18095016
[11] DeGroot DW, O'Connor FG, Roberts WO. Exertional heat stroke: an evidence based approach to clinical assessment and management[J]. Exp Physiol, 2022, 107(10): 1172-1183. doi: 10.1113/EP090488
[12] Giersch GEW, Garcia CK, Stachenfeld NS, et al. Are there sex differences in risk for exertional heat stroke? A translational approach[J]. Exp Physiol, 2022, 107(10): 1136-1143. doi: 10.1113/EP090402
[13] Belval LN, Giersch GEW, Adams WM, et al. Age-and Sex-Based Differences in Exertional Heat Stroke Incidence in a 7-Mile Road Race[J]. J Athl Train, 2020, 55(12): 1224-1229. doi: 10.4085/1062-6050-539-19
[14] May JE, Marques MB, Reddy VVB, et al. Three neglected numbers in the CBC: The RDW, MPV, and NRBC count[J]. Cleve Clin J Med, 2019, 86(3): 167-172. doi: 10.3949/ccjm.86a.18072
[15] Zheng YY, Wang L, Shi Q. Mean platelet volume(MPV)and platelet distribution width(PDW)predict clinical outcome of acute ischemic stroke: A systematic review and meta-analysis[J]. J Clin Neurosci, 2022, 101: 221-227. doi: 10.1016/j.jocn.2022.05.019
[16] Haybar H, Pezeshki SMS, Saki N. Evaluation of complete blood count parameters in cardiovascular diseases: An early indicator of prognosis?[J]. Exp Mol Pathol, 2019, 110: 104267. doi: 10.1016/j.yexmp.2019.104267
[17] Guo F, Zhu X, Qin X. Platelet Distribution Width in Hepatocellular Carcinoma[J]. Med Sci Monit, 2018, 24: 2518-2523. doi: 10.12659/MSM.909474
[18] Li C, Zhang H, Li S, et al. Prognostic Impact of Inflammatory Markers PLR, LMR, PDW, MPV in Medullary Thyroid Carcinoma[J]. Front Endocrinol(Lausanne), 2022, 13: 861869. doi: 10.3389/fendo.2022.861869
[19] Yang MH, Duan CJ, Liu SS, et al. Application of NLRP3 Inflammasome-related Modulators in Sepsis[J]. J Explor Res Pharmaco, 2022, 7(2): 104-111. doi: 10.14218/JERP.2021.00055
[20] Yin H, Wu M, Lu Y, et al. HMGB1-activatied NLRP3 inflammasome induces thrombocytopenia in heatstroke rat[J]. PeerJ, 2022, 10: e13799. doi: 10.7717/peerj.13799
[21] Botros M, Sikaris KA. The de ritis ratio: the test of time[J]. Clin Biochem Rev, 2013, 34(3): 117-130.
[22] Aksoy MNM, Turna F, Sahin I, et al. Is AST/ALT Ratio a Predictor of In-hospital Mortality in Pulmonary Embolism Patients?[J]. J Coll Physicians Surg Pak, 2022, 32(2): 171-176. doi: 10.29271/jcpsp.2022.02.171
[23] Liu H, Zha X, Ding C, et al. AST/ALT Ratio and Peripheral Artery Disease in a Chinese Hypertensive Population: A Cross-Sectional Study[J]. Angiology, 2021, 72(10): 916-922. doi: 10.1177/00033197211004410
[24] Liu Y, Zhao P, Cheng M, et al. AST to ALT ratio and arterial stiffness in non-fatty liver Japanese population: a secondary analysis based on a cross-sectional study[J]. Lipids Health Dis, 2018, 17(1): 275. doi: 10.1186/s12944-018-0920-4
[25] Geng Y, Ma Q, Liu YN, et al. Heatstroke induces liver injury via IL-1β and HMGB1-induced pyroptosis[J]. J Hepatol, 2015, 63(3): 622-633. doi: 10.1016/j.jhep.2015.04.010
[26] Li P, Yang L, Liu R, et al. The value of the exertional heat stroke score for the prognosis of patients with exertional heat stroke[J]. Am J Emerg Med, 2021, 50: 352-355. doi: 10.1016/j.ajem.2021.08.036
[27] Yokoyama K, Kaneko T, Ito A, et al. Sequential organ failure assessment score as a predictor of the outcomes of patients hospitalized for classical or exertional heatstroke[J]. Sci Rep, 2022, 12(1): 16373. doi: 10.1038/s41598-022-20878-1
-